The nurse obtains the following vital signs on an adult patient:

Question

T. 100.6°F BP 100/60, HR 110, respirations 36 . What is the first action by the nurse?
a. Offer oral fluids.
b. Begin an IV infusion.
c. Obtain a pulse oximetry reading.
d. Administer oxygen.

Answer 1

C
In this item, all vital signs values are slightly abnormal; however, the most significant abnormality is the respiratory rate of 36 breaths/min. Respiratory rate is a measure of the patient's general condition, but rate alone is not a good indicator of the adequacy of respirations or oxygenation. The nurse must also assess other characteristics of the respirations. If oxygenation must be carefully monitored or there is a concern regarding oxygenation, use a pulse oximeter to measure the patient's oxygenation saturation. The nurse may need to administer oxygen to this patient, given the respiratory rate of 36 breaths/min; however, the first action is to obtain a pulse oximeter reading. There is no evidence that the patient needs either oral or IV fluids.